Eclipse Marketing & Insurance Services : : SCIF

SCIF

Name:

Address:

City, State Zip:

Contact:

Telephone:

Fax:

Email:

Code	Classification	Estimated Annual Payroll



8810	Clerical
8742	Outside Sales

Workers Comp Policy Anniversary Date:

Expiring Premium:

Name of Current Insurer:

Workers Comp Claims in Past 5 Years?

If yes, have steps been taken to prevent future claims?